Which of the following manifestations would a nurse expect in a 70-year-old patient who has the diagnosis of osteoarthritis?
a. Swan neck deformity of the hand
b. Subluxation of the fingers
c. Heberden's nodes on the distal phalanges
d. Enlarged great toe
ANS: C
Herbeden's nodes are common in osteoarthritis. As the disease progresses, osteophytes develop in the joints of the fingers. Swan neck deformity and subluxation of the fingers are common in RA. An enlarged great toe is characteristic of gout.
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The nurse is speaking with a parent of a child with cerebral palsy who is also severely developmental delayed. On which of the following should the nurse follow up?
1. "I understand that my child will not be able to play the same as do other children the same age." 2. "I know my child will not be able to attend the same school as do other children his age." 3. "I understand that my child will not achieve the same milestones as do other children his age." 4. "I know my child will be able to perform at the same level as do other children the same age."
A client who experienced a severe head injury is demonstrating a lack of response to painful stimuli, pupils are unequal and fixed, and decorticate posturing. The nurse takes immediate steps, as the client is experiencing:
1. disorientation. 2. early increased intracranial pressure (IICP). 3. a subdural hematoma. 4. signs of late IICP.
The nurse administers 20 mg of furosemide (Lasix) to a patient by the intravenous (IV) route. Which action is most important for the nurse to take?
a. Give the drug slowly over at least 2 minutes. b. Check the patient carefully for symptoms of low blood glucose levels. c. Mix the drug with potassium chloride to prevent a rapid drop in serum potassium levels. d. Monitor the IV site after giving the drug because furosemide causes severe tissue damage if infiltration occurs.
A nurse implements an education program that incorporates computer games to reinforce learning for a group of older adults
Although the research demonstrates evidence of improved retention of this information, the nurse experiences exactly the opposite with this group. Which of the following is the most likely cause of such poor outcomes? a. Failure to consider client and setting differences b. Inadequate incorporation of evidence into practice c. Inferior quality of the available research evidence d. Lack of skills when evaluating the evidence